Healthcare Provider Details

I. General information

NPI: 1952399685
Provider Name (Legal Business Name): FAMILY & COSMETIC GENTLE DENTISTRY, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 EDEN AVE STE 209
EDINA MN
55436-2338
US

IV. Provider business mailing address

6600 FRANCE AVE S STE 415
EDINA MN
55435-1817
US

V. Phone/Fax

Practice location:
  • Phone: 952-929-0641
  • Fax:
Mailing address:
  • Phone: 952-224-9771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT LUTHER BODIN
Title or Position: PRESIDENT
Credential: DDS
Phone: 952-224-9771